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Complex cases
 

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Complex cases
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Comorbidity in the veteran population

Veterans commonly present with comorbid disorders and complex needs that require careful treatment planning. For example, up to 90 per cent of veterans with posttraumatic stress disorder (PTSD) will meet criteria for another mental health problem.

Using case formulation to understand complex veteran presentations

Case formulation assists in focussing on presenting problems that are likely to have the most impact on a veteran's recovery and helps set priorities for treatment.  Case formulation goes beyond summarising information gathered during assessment and provides an explanatory story that is used to focus treatment. 

The following case formulation model can be easily adapted to fit in with most treatment approaches. It takes into account factors that lead to and perpetuate presenting issues as well as the client’s vulnerabilities and strengths. A case formulation includes the following elements:

  • presenting problems
  • factors that cause the individual to be vulnerable to the development of these problems (predisposing factors)
  • factors that trigger the onset of the presenting problems (precipitating factors)
  • factors that might be barriers or supports for change (prognostic factors)

The case formulation culminates in the following element:

  • a hypothesis about the relationship between presenting problems and what maintains them (perpetuating factors).

Please refer to this one page case formulation template (PDF) .  In order for the case formulation to be a useful tool, it needs to move beyond describing or listing the above factors. It should describe the relationships between these factors and provide a coherent story about the way the veteran is presenting in counselling.

 

Treatment information: Sequencing

An important aspect of managing complex cases is the sequencing of treatment for comorbid conditions. Treatment sequencing tends to focus on those disorders which present the most severely, are the most disabling, and are the most likely to lead to further harm.  Effective treatment for complex presentations also addresses problems that are likely to impact on the veteran’s ability to engage in treatment. Problems that impair alertness, motivation, attention and emotional stability must be resolved before treatments that are dependent on these characteristics can begin. Suggestions for treatment sequencing for commonly co-existing mental health problems in veterans are outlined below.

When depression and high-risk alcohol use conditions are severe, treat the alcohol problems first, maintaining active monitoring of the risk of self-harm or suicide. This is because depression may have an organic basis associated with alcohol dependence, including delirium, impaired liver function or systemic illness. Treatment for depression without a reduction in alcohol use, will only have limited effectiveness. Depression may lift once the veteran is successfully treated for high-risk alcohol use. If both conditions are mild to moderate in severity, treatments can commence simultaneously.

 

Treatment for PTSD and high-risk alcohol use can commence simultaneously, excluding the trauma-focussed component. The trauma-focussed component should not commence until the veteran has demonstrated a capacity to manage distress without resorting to alcohol. Once the veteran has reached this stage, practitioners can begin the trauma-focussed component of PTSD treatment.

 

Where conditions are severe, treat the alcohol use first, with active monitoring of the risk of self-harm or suicide. Initial phases of PTSD treatment, excluding trauma-focussed treatment, can commence simultaneously with the treatment of alcohol-use problems. Where all conditions are mild to moderate, simultaneous treatment can commence, excluding the trauma-focussed component of PTSD, until the veteran is able to tolerate two to three days per week without using alcohol.

 

Where PTSD, depression and panic disorder and/or generalised anxiety disorder (GAD) are severe, treat the depression first. This is because depression has been demonstrated to impair the effective treatment of anxiety disorders. If the conditions are mild to moderate, treat the PTSD first. This is because improvements in PTSD are likely to result in reductions in demoralisation and depression.

 

Where moderate to severe depression and panic disorder and/or GAD are present, focus on treating the depression first, ensuring you include breathing control to reduce panic. This is because depression is potentially life threatening, but also because there is evidence that poor morale and impaired attention will impair learning of arousal management, attention to exposure cues and compliance with self-care treatment.

 

Recommended readings and online resources

  • Case Formulation: is a DVA online training program that assists providers to make better sense of complexity, and design and plan treatment in collaboration with their patient.
  • Tarrier, N. et al. (Ed). Treating Complex Cases: The Cognitive Behavioural Therapy Approach. John Wiley & Sons: United Kingdom. This clinical guidebook presents a case-formulation driven approach to the systematic management of complexity within a cognitive behavioural framework. It draws on the experience of key cognitive behavioural therapists.
  • Persons, J. B. (2005). Empiricism, mechanism, and the practice of cognitive-behavior therapy. Behavior Therapy, 36, 107-118. doi: 10.1016/S0005-7894(05)80059-0. This article provides a rationale for using case formulation. It argues that a case formulation-driven approach to clinical work facilitates the use of empirically supported treatments.
  • Kuyken, Padesky and Dudley (2009). Collaborative case conceptualization: working effectively with clients in cognitive behavioural therapy. This book is a step by step guide to using a cognitive case formulation approach with clients.

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